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Kavitt RT, Gralnek IM. Ideal strategy for nonvariceal upper gastrointestinal bleeding. Curr Opin Gastroenterol 2024; 40:342-347. [PMID: 38967918 DOI: 10.1097/mog.0000000000001043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/06/2024]
Abstract
PURPOSE OF REVIEW Over 300 000 hospital admissions in the United States each year are due to patients with upper gastrointestinal (GI) bleeding (UGIB). Common etiologies of nonvariceal UGIB include peptic ulcers, mucosal erosions of the esophagus, stomach or duodenum, Mallory-Weiss tears, Dieulafoy lesions, upper GI tract malignancy, or other etiology. RECENT FINDINGS Peptic ulcers classified as Forrest Ia, Ib, or IIa require endoscopic hemostasis, while IIb ulcers may be considered for endoscopic clot removal with endoscopic treatment of any underlying major stigmata. Endoscopic hemostasis for ulcers classified as Forrest IIc or III is not advised due to the low risk of recurrent bleeding. Endoscopic hemostasis in ulcer bleeding can be achieved using injection, thermal, and/or mechanical modalities. SUMMARY This review focuses on the currently recommended endoscopic therapies of patients presenting with acute nonvariceal upper gastrointestinal hemorrhage.
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Affiliation(s)
- Robert T Kavitt
- Section of Gastroenterology, Hepatology, and Nutrition, University of Chicago, Chicago, Illinois, USA
| | - Ian M Gralnek
- Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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2
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Aabdi B, Kharrasse G, Zazour A, Koulali H, Elmqaddem O, Zahi I. Clinical, endoscopic and therapeutic features of bleeding Dieulafoy's lesions: case series and literature review. BMJ Open Gastroenterol 2024; 11:e001299. [PMID: 38789268 PMCID: PMC11129027 DOI: 10.1136/bmjgast-2023-001299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/21/2024] [Indexed: 05/26/2024] Open
Abstract
OBJECTIVE Dieulafoy's lesions (DLs) are a rare but potentially life-threatening source of gastrointestinal (GI) haemorrhage. They are responsible for roughly 1%-6.5% of all cases of acute non-variceal GI bleeding.Here, we describe retrospectively the clinical and endoscopic features, review the short-term and long-term outcomes of endoscopic management of bleeding DLs and we identify rate and risk factors, of recurrence and mortality in our endoscopic unit. DESIGN Data were collected from patients presenting with GI haemorrhagic secondary to DLs between January 2018 and August 2023. Patients' medical records as well as endoscopic databases were retrospectively reviewed. Demographic data, risk factors, bleeding site, outcomes of endoscopy techniques, recurrence and mortality rate were taken into account. RESULTS Among 1170 cases of GI bleeding, we identified only seven cases involving DLs. Median age was 74 years, with a male-to-female ratio of 2.5. 75% of patients had significant comorbidities, mainly cardiovascular diseases. Only anticoagulant and antiplatelet agents were significantly associated with DLs. All patients were presented with GI bleeding as their initial symptom. The initial endoscopy led to a diagnosis in 85% of the cases. Initial haemostasis was obtained in all patients treated endoscopically. Nevertheless, the study revealed early recurrence in two out of three patients treated solely with epinephrine injection or argon plasma coagulation. In contrast, one of three patients who received combined therapy, experienced late recurrence (average follow-up of 1 year). Pathological diagnosis was necessary in one case. One patient (14%) died of haemorrhagic shock. Average length of hospital stay was 3 days. CONCLUSION Although rare, DLs may be responsible for active, recurrent and unexplained GI bleeding. Thanks to the emergence of endoscopic therapies, the recurrence rate has decreased and the prognosis has highly improved. Therefore, the endoscopic approach remains the first choice to manage bleeding DLs.
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Affiliation(s)
- Basma Aabdi
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
| | - Ghizlane Kharrasse
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
| | - Abdelkrim Zazour
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Hajar Koulali
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Ouiam Elmqaddem
- Digestive Disease Research Laboratory (LARMAD), Mohammed I University, Faculty of Medicine and Pharmacy, Oujda, Morocco, Oujda, Morocco
| | - Ismaili Zahi
- Gastroenterology, Mohammed VI University Hospital Oujda, Morocco, Oujda, Morocco
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Wang Y, Bansal P, Li S, Iqbal Z, Cheryala M, Abougergi MS. Dieulafoy's lesion of the upper GI tract: a comprehensive nationwide database analysis. Gastrointest Endosc 2021; 94:24-34.e5. [PMID: 33359438 DOI: 10.1016/j.gie.2020.12.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 12/03/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS We sought to determine the incidence, risk factors, and treatment outcomes of Dieulafoy's lesion of the upper GI tract (UDL) hemorrhage among adult patients in the United States. METHODS UDL and non-Dieulafoy upper GI bleeding (UGIB) were identified from the Nationwide Inpatient Sample and Nationwide Readmission Database using International Classification of Diseases, Tenth Revision, Clinical Modification and Procedure Coding System codes. Multivariate logistic (binary) and linear (continuous) regressions were used to model dependent variables. RESULTS The incidence of UDL hemorrhage was 1.6 of 100,000 persons. Patients with UDL and UGIB who required endoscopic therapeutic intervention had similar in-hospital (adjusted odds ratio [aOR], .77; 95% confidence interval [CI], .42-1.43; P = .41) mortality rates. UDL was associated with more severe systemic illness, including higher rates of mechanical ventilation (aOR, 1.52; 95% CI, 1.07-2.15; P < .05), hypovolemic shock (aOR, 1.50; 95% CI, 1.08-2.08; P < .05), acute kidney injury (aOR, 1.25; 95% CI, 1.02-1.54; P < .05), and multiple endoscopies (aOR, 1.57; 95% CI, 1.28-1.93; P < .05) compared with other UGIB patients who required endoscopic therapeutic intervention. UDL was also associated with higher 30-day all-cause (aOR, 1.23; 95% CI, 1.12-1.35; P < .05) and recurrent bleeding-related (aOR, 1.73; 95% CI, 1.45-2.06; P < .05) readmissions. The rate of successful endoscopic treatment was 96.81%. CONCLUSIONS UDL hemorrhage is an uncommon but highly morbid condition. Current UDL treatment modalities are effective in reducing mortality. Further investigations are warranted to lower recurrent bleeding rates.
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Affiliation(s)
- Yichen Wang
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Pardeep Bansal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA; Division of Gastroenterology, Regional Hospital and Moses Taylor Hospital, Scranton, Pennsylvania, USA
| | - Si Li
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Zaid Iqbal
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Mahesh Cheryala
- Department of Internal Medicine, Wright Center for Graduate Medical Education, Scranton, Pennsylvania, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, South Carolina, USA; Division of Gastroenterology, Department of Internal Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA
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Zamora-Soler JÁ, Maturana-Ibáñez V. Tratamiento quirúrgico de la hemorragia digestiva alta por enfermedad de Dieulafoy. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
La enfermedad de Dieulafoy constituye menos del 2 % de las causas de hemorragia digestiva alta. Corresponde a la presencia de un vaso sanguíneo arterial de trayecto tortuoso, que protruye a través de un defecto mucoso localizado, generalmente, proximal en el estómago. Se presenta como una hematemesis masiva, a veces recurrente, con inestabilidad hemodinámica.
La endoscopia es el método diagnóstico y terapéutico de elección. Si esta fracasa, está indicado practicar una angiografía selectiva que permita identificar el punto sangrante y producir un embolismo. En algunas ocasiones, ninguna de estas dos técnicas consigue detener la hemorragia, en cuyo caso está indicada una cirugía urgente. Se deben practicar resecciones gástricas limitadas (gastrectomías en cuña o tubulares) a la zona sangrante localizada mediante las pruebas anteriores; así, se evitan grandes gastrectomías que implican la práctica de anastomosis por el gran riesgo de dehiscencia que estas últimas cuando hay inestabilidad hemodinámica.
Se presenta el caso de un paciente con hemorragia digestiva alta secundaria a enfermedad de Dieulafoy, que precisó intervención quirúrgica urgente por la imposibilidad de resolver el sangrado mediante endoscopia. Se describen el diagnóstico y el tratamiento de la enfermedad de Dieulafoy como causa de hemorragia digestiva alta en el adulto, y se presenta una revisión de la literatura científica.
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Sakai E, Ohata K, Nakajima A, Matsuhashi N. Diagnosis and therapeutic strategies for small bowel vascular lesions. World J Gastroenterol 2019; 25:2720-2733. [PMID: 31235995 PMCID: PMC6580356 DOI: 10.3748/wjg.v25.i22.2720] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/21/2019] [Accepted: 05/03/2019] [Indexed: 02/06/2023] Open
Abstract
Small bowel vascular lesions, including angioectasia (AE), Dieulafoy’s lesion (DL) and arteriovenous malformation (AVM), are the most common causes of obscure gastrointestinal bleeding. Since AE are considered to be venous lesions, they usually manifest as a chronic, well-compensated condition. Subsequent to video capsule endoscopy, deep enteroscopy can be applied to control active bleeding or to improve anemia necessitating blood transfusion. Despite the initial treatment efficacy of argon plasma coagulation (APC), many patients experience re-bleeding, probably because of recurrent or missed AEs. Pharmacological treatments can be considered for patients who have not responded well to other types of treatment or in whom endoscopy is contraindicated. Meanwhile, a conservative approach with iron supplementation remains an option for patients with mild anemia. DL and AVM are considered to be arterial lesions; therefore, these lesions frequently cause acute life-threatening hemorrhage. Mechanical hemostasis using endoclips is recommended to treat DLs, considering the high re-bleeding rate after primary APC cauterization. Meanwhile, most small bowel AVMs are large and susceptible to re-bleeding therefore, they usually require surgical resection. To achieve optimal diagnostic and therapeutic approaches for each type of small bowel lesion, the differences in their epidemiology, pathology and clinical presentation must be understood.
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Affiliation(s)
- Eiji Sakai
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Ken Ohata
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
| | - Atsushi Nakajima
- Division of Gastroenterology and Hepatology, Yokohama City University School of Medicine, Yokohama 236-0004, Japan
| | - Nobuyuki Matsuhashi
- Department of Gastroenterology, NTT Medical Center Tokyo, Tokyo 141-8625, Japan
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A Retrospective Analysis of Cyanoacrylate Injection versus Hemoclip Placement for Bleeding Dieulafoy's Lesion in Duodenum. Gastroenterol Res Pract 2018; 2018:3208690. [PMID: 29780411 PMCID: PMC5892292 DOI: 10.1155/2018/3208690] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 01/05/2018] [Accepted: 01/28/2018] [Indexed: 12/14/2022] Open
Abstract
Background Duodenal Dieulafoy's lesion (DL) is a rare disease that may lead to lethal hemorrhage in the upper gastrointestinal tract. The best technique for endoscopic intervention still remains unclear. In the present study, we performed a retrospective analysis of cyanoacrylate injection versus hemoclip placement for treating bleeding DLs. Materials and Methods We retrospectively analyzed eighteen patients from three medical centers between October 2008 and February 2016; six patients received cyanoacrylate injection, while hemoclips were placed in 12 patients during the upper gastrointestinal endoscopy. Results All patients received first endoscopic examination and/or endotherapy within 12 hours of admission to hospital. No difference was observed in the primary hemostasis rate or the recurrent hemorrhage rate between the cyanoacrylate injection (CI) group and the hemoclip placement (HP) group, except that in one patient from the HP group melena was found three days after the first endotherapy. This patient received cyanoacrylate injection once again. Conclusion Both cyanoacrylate injection and hemoclip placement are effective in treating duodenal DL, and neither of them causes significant side effects.
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Abstract
Non-variceal upper gastrointestinal bleeding continues to be an important cause of morbidity and mortality. The most common causes include peptic ulcer disease, Mallory-Weiss syndrome, erosive gastritis, duodenitis, esophagitis, malignancy, angiodysplasias and Dieulafoy's lesion. Initial assessment and early aggressive resuscitation significantly improves outcomes. Upper gastrointestinal endoscopy continues to be the gold standard for diagnosis and treatment. We present a comprehensive review of literature for the evaluation and management of non-variceal upper gastrointestinal bleeding.
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Affiliation(s)
- Ronald Samuel
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Mohammad Bilal
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551.
| | - Obada Tayyem
- Department of Internal Medicine, University of Texas Medical Branch, Galveston, TX
| | - Praveen Guturu
- Division of Gastroenterology & Hepatology, University of Texas Medical Branch, 7400 Jones Drive, Apt 724, Galveston, TX 77551
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Inayat F, Amjad W, Hussain Q, Hurairah A. Dieulafoy's lesion of the duodenum: a comparative review of 37 cases. BMJ Case Rep 2018; 2018:bcr-2017-223246. [PMID: 29472423 PMCID: PMC5847980 DOI: 10.1136/bcr-2017-223246] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2018] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy's lesion is an abnormally large, tortuous, submucosal vessel that erodes the overlying epithelium without primary ulceration or erosion. The lesion predominantly occurs in the proximal stomach but it is also reported in extragastric sites. The pathogenesis and precipitating factors are poorly understood. Patients frequently present with gastrointestinal haemorrhage that can range from being self-limited to massive life threatening. Although there are no standard guidelines, endoscopy has significantly impacted the diagnosis and management. This review outlines our current understanding of the epidemiology of and risk factors for Dieulafoy's lesion of the duodenum, the pathophysiology of this disorder, and currently available approaches to diagnosis and management.
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Affiliation(s)
| | - Waseem Amjad
- Northwell-Long Island Jewish Forest Hills Hospital, Forest Hills, NY, USA
| | | | - Abu Hurairah
- SUNY Downstate Medical Center, Brooklyn, NY, USA
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9
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Postural Syncope and Constipation: An Unusual Presentation of a Duodenal Dieulafoy's Lesion. Case Rep Gastrointest Med 2017; 2017:6983434. [PMID: 28367340 PMCID: PMC5359456 DOI: 10.1155/2017/6983434] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 02/23/2017] [Indexed: 11/17/2022] Open
Abstract
Dieulafoy lesions are a rare etiology of gastrointestinal bleeding from a large caliber-persistent tortuous submucosal artery. They account for 1-2% of all causes of acute gastrointestinal hemorrhage with 80%–95% of these lesions located in the stomach along the lesser curvature. One-third of these lesions present at an extragastric location, with the proximal duodenum accounting for 15% of them. We present a 21-year-old male with no significant past medical history or risk factors, who presented with repeated syncopal episodes followed by hematemesis, found to have a Dieulafoy lesion located at the duodenal bulb. This lesion was diagnosed and successfully treated via upper endoscopy with epinephrine injection and the application of 2 endoscopic clips.
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10
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Chen X, Cao H, Wang S, Wang D, Xu M, Piao M, Wang B. Endoscopic submucosal dissection for silent gastric Dieulafoy lesions mimicking gastrointestinal stromal tumors: Report of 7 cases-a case report series. Medicine (Baltimore) 2016; 95:e4829. [PMID: 27603399 PMCID: PMC5023922 DOI: 10.1097/md.0000000000004829] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Dieulafoy lesion is a rare but serious cause of gastrointestinal hemorrhage. However, some cases can be occasionally found without bleeding during the endoscopic screening, and the management remains unclear. The aim of this article was to report the efficacy and safety of endoscopic submucosal dissection (ESD) for silent gastric Dieulafoy lesions, which presented as protrusion lesions mimicking gastrointestinal stromal tumors (GISTs). METHODS Data from the patients with gastric protrusion lesions who underwent ESD from September 2008 to April 2016 in General Hospital, Tianjin Medical University, China were recorded. Seven cases with pathological diagnosis of Dieulafoy lesion without bleeding were enrolled for further analysis. RESULTS A total of 7 patients (2 males and 5 females) with mean age of 57.7 ± 4.15 years were pathologically diagnosed as Dieulafoy lesion. Four of the lesions were located in gastric antrum, 2 in the fundus, and 1 in the body of stomach, respectively. The mean sizes of the Dieulafoy lesions under white light endoscopy and endoscopic ultrasonography (EUS) were 1.06 ± 0.28 and 0.84 ± 0.29 cm. The origins of these lesions were submucosa (6/7, 85.7%) and muscularis propria (1/7, 14.3%). Three of them appeared with mixed echo under EUS, 3 with hypoechogenicity, and 1 with hyperechogenicity. En bloc complete resection was achieved in all the lesions by ESD with average time of 76.00 ± 16.86 minutes, and no intraoperative bleeding happened. In addition, all patients were followed up for 1 to 53 months, and no recurrence or long-term complications was observed. CONCLUSION Therefore, ESD can be an effective and safe treatment for silent gastric Dieulafoy lesions with clinical presentations of submucosal protrusion lesions mimicking GISTs.
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Affiliation(s)
- Xue Chen
- Department of Gastroenterology and Hepatology
| | - Hailong Cao
- Department of Gastroenterology and Hepatology
- Correspondence: Hailong Cao, Department of Gastroenterology and Hepatology, General Hospital, Tianjin Medical University, Heping District 154 Anshan Road, Tianjin 300052, China (e-mail: )
| | - Sinan Wang
- Department of Gastroenterology and Hepatology
| | - Dan Wang
- Department of Pathology, General Hospital, Tianjin Medical University, Tianjin, China
| | - Mengque Xu
- Department of Gastroenterology and Hepatology
| | - Meiyu Piao
- Department of Gastroenterology and Hepatology
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Seretny M, While B, Manji H. Dieulafoy's Lesion; A Diagnostic ‘Must Know’ for Critical Care Practitioners. J Intensive Care Soc 2016. [DOI: 10.1177/175114370700800218] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Marta Seretny
- F1 Doctor, Anaesthetics Department Milton Keynes General Hospital
| | - Ben While
- Anaesthetics Department Milton Keynes General Hospital
| | - Hamid Manji
- Consultant Anaesthetist Milton Keynes General Hospital
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12
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Aoyama T, Fukumoto A, Mukai S, Ueda H, Kimura S, Nagata S. Successful Endoscopic Treatment of an Actively Bleeding Jejunal Dieulafoy's Lesion. Intern Med 2016; 55:1739-41. [PMID: 27374674 DOI: 10.2169/internalmedicine.55.6381] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Although small bowel endoscopy is commonly performed, cases of ongoing bleeding from small bowel lesions have not been commonly encountered. In the present report, we describe a case of successful endoscopic treatment of an actively bleeding jejunal Dieulafoy's lesion in a 79-year-old man with persistent anemia and melena. Capsule endoscopy indicated active bleeding in the jejunum. Thereafter, double-balloon endoscopy-performed via the oral approach-showed active bleeding from a jejunal Dieulafoy's lesion, which was treated using argon plasma coagulation and hemoclips. The melena subsequently resolved, and the patient's condition improved after the endoscopic treatment.
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Affiliation(s)
- Taiki Aoyama
- Department of Gastroenterology, Hiroshima City Asa Citizens Hospital, Japan
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Lipka S, Rabbanifard R, Kumar A, Brady P. A single-center United States experience with bleeding Dieulafoy lesions of the small bowel: diagnosis and treatment with single-balloon enteroscopy. Endosc Int Open 2015; 3:E339-45. [PMID: 26356602 PMCID: PMC4554498 DOI: 10.1055/s-0034-1391901] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Accepted: 02/23/2015] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION A Dieulafoy lesion (DL) of the small bowel can cause severe gastrointestinal bleeding, and presents a difficult clinical setting for endoscopists. Limited data exists on the therapeutic yield of treating DLs of the small bowel using single-balloon enteroscopy (SBE). METHODS Data were collected from Tampa General Hospital a 1 018-bed teaching hospital affiliated with University of South Florida in Tampa, Florida. Patients were selected from a database of patients that underwent SBE from January 2010 - August 2013. RESULTS Eight patients were found to have DL an incidence of 2.6 % of 309 SBE performed for obscure gastrointestinal bleeding. 7/8 were identified in the jejunum, with one found in the duodenum. The mean age of patients with DL was 71.5 years old. 6/8 patients were on some form of anticoagulant/antiplatelet agent. The primary modality of therapy employed was electrocautery, multipolar electrocoagulation in seven patients and APC (argon plasma coagulation) in one patient. In three patients, electrocoagulation was unsuccessful and hemostasis was achieved with clip placement. Three patients required repeat SBE with one found to have rebleeding from a failed clip with hemostasis achieved upon reapplication of one clip. CONCLUSION In our United States' experience, SBE offers a reasonable therapeutic approach to treat DL of the small bowel with low rates of rebleeding, no adverse events, and no patient requiring surgery.
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Affiliation(s)
- Seth Lipka
- University of South Florida Morsani College of Medicine, Department of Medicine, Tampa, Florida, United States,Corresponding author Seth Lipka, M.D. 12901 Bruce B. Downs Blvd. MDC 72Tampa, Florida 33612United States(813) 805–9863
| | - Roshanak Rabbanifard
- University of South Florida Morsani College of Medicine, Division of Digestive Diseases and Nutrition, Tampa, Florida, United States
| | - Ambuj Kumar
- University of South Florida Morsani College of Medicine, Department of Medicine, Division of Evidence Based Medicine and Outcomes Research, Tampa, Florida, United States
| | - Patrick Brady
- University of South Florida Morsani College of Medicine, Division of Digestive Diseases and Nutrition, Tampa, Florida, United States
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14
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Abstract
Dieulafoy's lesion (DL) is a persistently wide caliber artery that is observed more frequently at the fifth decade of life in the male population with multiple comorbidities. There are a variety of endoscopic therapies that have been used to treat DL; however, there are no clear guidelines on the best treatment modality. This article systematically reviews the diagnosis, the most commonly reported therapies of DL, and offers a suggested algorithm based upon efficacy of treatment such as initial hemostasis, rebleeding rates, and mortality.
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15
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Khan R, Mahmad A, Gobrial M, Onwochei F, Shah K. The Diagnostic Dilemma of Dieulafoy's Lesion. Gastroenterology Res 2015; 8:201-206. [PMID: 27785297 PMCID: PMC5040527 DOI: 10.14740/gr671w] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/15/2015] [Indexed: 12/17/2022] Open
Abstract
Dieulafoy’s lesion (DL) is a relatively rare condition which carries a significantly high risk for mortality. A tortuous large arteriole in the wall of the stomach can result in significant gastrointestinal (GI) hemorrhage which can result in detrimental complications. Although it only accounts for about 1% of all GI bleeding, it has been considered to be one of the most underrecognized conditions. This train of thought may unfortunately be related to the difficulty in its diagnosis. After conducting a Medline search of the medical literature, with a focus on current PubMed articles, a thorough examination of updated diagnostic and treatment approaches was compared. Diagnostic techniques in the analysis and treatment of DLs continue to be limited to this day. Endoscopy remains as the main diagnostic and therapeutic tool; however, it continues to have its limitations. Other alternatives include but are not limited to angiography and surgical interventions which at times can be more successful. Diagnostic improvements and research for the detection of DL continue to advance; however, they remain limited in their capabilities. Further analysis and workup needs to be conducted in order to reduce hospital stay and improve survival.
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Affiliation(s)
- Rafay Khan
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Abdul Mahmad
- Internal Medicine Department, Raritan Bay Medical Center, 530 New Brunswick Avenue, Perth Amboy, NJ 08861, USA
| | - Mark Gobrial
- Internal Medicine Department, Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
| | - Francis Onwochei
- Internal Medicine Department, Jersey City Medical Center, 355 Grand St, Jersey City, NJ 07302, USA
| | - Kunal Shah
- St. George's University School of Medicine, University Centre, Grenada, West Indies
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Shin HJ, Ju JS, Kim KD, Kim SW, Kang SH, Kang SH, Moon HS, Sung JK, Jeong HY. Risk Factors for Dieulafoy Lesions in the Upper Gastrointestinal Tract. Clin Endosc 2015; 48:228-33. [PMID: 26064823 PMCID: PMC4461667 DOI: 10.5946/ce.2015.48.3.228] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Revised: 10/13/2014] [Accepted: 10/19/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND/AIMS The purpose of this study is to verify the risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract. METHODS A case-control study was performed by reviewing the electronic medical records of 42 patients who were admitted to a tertiary medical center in the Daejeon region for Dieulafoy lesions from September 2008 to October 2013, and the records of 132 patients who were admitted during the same period and who underwent endoscopic examination for reasons other than bleeding. We analyzed clinical and endoscopic findings retrospectively, and searched for risk factors associated with Dieulafoy lesion formation. RESULTS All 42 patients diagnosed with Dieulafoy lesion had accompanying bleeding, and the location of the bleeding was proximal in 25 patients (59.5%), the middle portion in seven patients (16.7%), and distal in 10 patients (23.8%). Antiplatelet agents (p=0.022) and alcohol (p=0.001) use showed statistically significant differences between the two groups. The odds ratios (95% confidence intervals) of the two factors were 2.802 (1.263 to 6.217) and 3.938 (1.629 to 9.521), respectively. CONCLUSIONS This study showed that antiplatelet agents and alcohol consumption were risk factors associated with Dieulafoy lesion formation in the upper gastrointestinal tract.
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Affiliation(s)
- Hae Jin Shin
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jong Seok Ju
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Ki Dae Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Seok Won Kim
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sung Hoon Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Sun Hyung Kang
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hee Seok Moon
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Kyu Sung
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Hyun Yong Jeong
- Department of Gastroenterology, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Jeon HK, Kim GH. Endoscopic Management of Dieulafoy's Lesion. Clin Endosc 2015; 48:112-120. [PMID: 25844338 PMCID: PMC4381137 DOI: 10.5946/ce.2015.48.2.112] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Revised: 11/02/2014] [Accepted: 11/03/2014] [Indexed: 12/11/2022] Open
Abstract
A Dieulafoy's lesion is a vascular abnormality consisting of a large caliber-persistent tortuous submucosal artery. A small mucosal defect with the eruption of this protruding vessel can cause bleeding. In fact, a Dieulafoy's lesion is a relatively rare but potentially life-threatening condition. It accounts for 1% to 2% of cases of acute gastrointestinal bleeding. Although there is no consensus on the treatment of Dieulafoy's lesions; treatment options depend on the mode of presentation, site of the lesion, and available expertise. Endoscopic therapy is usually successful in achieving primary hemostasis, with hemostasis success rates reaching 75% to 100%. Although various therapeutic endoscopic methods are used to control bleeding in Dieulafoy's lesions, the best method for endoscopic intervention is not clear. Combination endoscopic therapy is known to be superior to monotherapy because of a lower rate of recurrent bleeding. In addition, mechanical therapies including hemostatic clipping and endoscopic band ligation are more effective and successful in controlling bleeding than other endoscopic methods. Advances in endoscopic techniques have reduced mortality in patients with Dieulafoy's lesion-from 80% to 8%-and consequently, the need for surgical intervention has been reduced. Currently, surgical intervention is used for cases that fail therapeutic endoscopic or angiographic interventions.
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Affiliation(s)
- Hye Kyung Jeon
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
| | - Gwang Ha Kim
- Department of Internal Medicine, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea
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Jamanca-Poma Y, Velasco-Guardado A, Piñero-Pérez C, Calderón-Begazo R, Umaña-Mejía J, Geijo-Martínez F, Rodríguez-Pérez A. Prognostic factors for recurrence of gastrointestinal bleeding due to Dieulafoy's lesion. World J Gastroenterol 2012; 18:5734-8. [PMID: 23155314 PMCID: PMC3484342 DOI: 10.3748/wjg.v18.i40.5734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2012] [Revised: 07/26/2012] [Accepted: 07/28/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To analyze the effectiveness of the endoscopic therapy and to identify prognostic factors for recurrent bleeding.
METHODS: Retrospective study of patients with gastrointestinal bleeding secondary to Dieulafoy’s lesion (DL) from 2005 to 2011. We analyzed the demographic characteristics of the patients, risk factors for gastrointestinal bleeding, endoscopic findings, characteristics of the endoscopic treatment, and the recurrence of bleeding. We included cases in which endoscopy described a lesion compatible with Dieulafoy. We excluded patients who had potentially bleeding lesions such as angiodysplasia in other areas or had undergone other gastrointestinal endoscopic procedures.
RESULTS: Twenty-nine patients with DL were identified. Most of them were men with an average age of 71.5 years. Fifty-five percent of the patients received antiaggregatory or anticoagulant therapy. The most common location for DL was the stomach (51.7%). The main type of bleeding was oozing in 65.5% of cases. In 27.6% of cases, there was arterial (spurting) bleeding, and 6.9% of the patients presented with an adherent clot. A single endoscopic treatment was applied to nine patients (31%); eight of them with adrenaline and one with argon, while 69% of the patients received combined treatment. Six patients (20.7%) presented with recurrent bleeding at a median of 4 d after endoscopy (interquartile range = 97.75). Within these six patients, the new endoscopic treatment obtained a therapeutic success of 100%. The presence of arterial bleeding at endoscopy was associated with a higher recurrence rate for bleeding (50% vs 33.3% for other type of bleeding) [P = 0.024, odds ratio (OR) = 8.5, 95% CI = 1.13-63.87]. The use of combined endoscopic treatment prevented the recurrence of bleeding (10% vs 44.4% of single treatment) (P = 0.034, OR = 0.14, 95% CI = 0.19-0.99).
CONCLUSION: Endoscopic treatment of DL is safe and effective. Adrenaline monotherapy and arterial (spurting) bleeding are associated with a high rate of bleeding recurrence.
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Ahn DW, Lee SH, Park YS, Shin CM, Hwang JH, Kim JW, Jeong SH, Kim N, Lee DH. Hemostatic efficacy and clinical outcome of endoscopic treatment of Dieulafoy's lesions: comparison of endoscopic hemoclip placement and endoscopic band ligation. Gastrointest Endosc 2012; 75:32-8. [PMID: 22100302 DOI: 10.1016/j.gie.2011.08.038] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2011] [Accepted: 08/20/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND The most suitable mechanical endoscopic hemostasis for a bleeding Dieulafoy's lesion (DL) is not yet well established. OBJECTIVE To compare the hemostatic efficacy and clinical outcome of endoscopic hemoclip placement (EHP) and endoscopic band ligation (EBL). DESIGN Retrospective, single-center study. SETTING A tertiary-care referral university hospital. PATIENTS Sixty-six patients who received mechanical endoscopic hemostasis for bleeding DLs. INTERVENTIONS Endoscopic hemostasis. MAIN OUTCOME MEASUREMENT Primary hemostasis and rebleeding rates. RESULTS DLs accounted for 3.8% of cases of acute nonvariceal upper GI bleeding during the study period. Active bleeding from DLs was noted in 34 patients (51.5%). EHP and EBL were performed as a method of endoscopic hemostasis in 34 and 32 patients, respectively. There were no significant differences between the 2 groups with respect to baseline characteristics (except comorbidities) and endoscopic features of DLs. Primary hemostasis was achieved in all 66 patients (100%). There were 6 cases of recurrent bleeding: 5 (14.7%) and 1 (3.1%) in the EHP and EBL groups, respectively. Secondary hemostasis was achieved with endoscopic treatment and angiographic embolization in 5 patients and 1 patient, respectively, and no patients required surgery. The mean procedure time of endoscopic hemostasis was significantly longer in the EHP group (19.1 vs 11.5 minutes, P = .015). There was no bleeding-related mortality. LIMITATIONS Retrospective analysis. CONCLUSIONS Both EHP and EBL are suitable for the treatment of bleeding DLs. EBL can be used as an initial hemostatic method for bleeding DLs because of a favorable clinical outcome comparable to that with EHP and a shorter procedure time.
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Affiliation(s)
- Dong-Won Ahn
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea
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Dulic-Lakovic E, Dulic M, Hubner D, Fuchssteiner H, Pachofszky T, Stadler B, Maieron A, Schwaighofer H, Püspök A, Haas T, Gahbauer G, Datz C, Ordubadi P, Holzäpfel A, Gschwantler M. Bleeding Dieulafoy lesions of the small bowel: a systematic study on the epidemiology and efficacy of enteroscopic treatment. Gastrointest Endosc 2011; 74:573-80. [PMID: 21802676 DOI: 10.1016/j.gie.2011.05.027] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2011] [Accepted: 05/05/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Dieulafoy lesions consist of aberrant submucosal arteries, which can cause severe GI bleeding. The predominant location of Dieulafoy lesions is the upper GI tract. OBJECTIVE To our best knowledge, this is the first systematic study on the frequency of bleeding from Dieulafoy lesions in the small bowel and the efficacy of enteroscopic therapy regarding primary hemostasis and long-term follow-up. DESIGN Multicenter, retrospective, observational study. SETTING Nine Austrian centers doing double-balloon enteroscopy or single-balloon enteroscopy. PATIENTS This study involved 284 consecutive patients who were referred for double-balloon enteroscopy or single-balloon enteroscopy because of suspicion of mid-GI bleeding. INTERVENTION A total of 317 double-balloon enteroscopy and 78 single-balloon enteroscopy procedures were performed in 284 patients with suspected mid-GI bleeding. MAIN OUTCOME MEASUREMENTS Demographic, clinical, procedural, and outcome data were collected. RESULTS A Dieulafoy lesion in the small bowel was identified as the source of mid-GI bleeding in 3.5% of patients, with a mean of 1.5 enteroscopy sessions required per diagnosis. In 9 cases the Dieulafoy lesion was found by enteroscopy from an oral approach, and in 1 patient the lesion was found by an anal approach. In all patients primary endoscopic hemostasis was successful. Eight of 10 patients were free from rebleeding episodes (median follow-up 14.5 months, interquartile range 10.0-17.5 months). In 2 of 10 patients, rebleeding occurred, and a surgical intervention was necessary. LIMITATIONS Retrospective study. CONCLUSION Bleeding from Dieulafoy lesions of the small bowel seems to occur more frequently than previously estimated. Most of these lesions are located in the proximal jejunum and can be managed successfully by enteroscopy. After successful endoscopic hemostasis, rebleeding episodes occur in only 20% of patients.
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Dieulafoy lesions of the GI tract: localization and therapeutic outcomes. Dig Dis Sci 2010; 55:3436-41. [PMID: 20848205 DOI: 10.1007/s10620-010-1385-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2010] [Accepted: 08/02/2010] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Dieulafoy lesions are a rare cause of gastrointestinal hemorrhage with a striking presentation because of rapid blood loss. Endoscopic therapy is usually successful at achieving primary hemostasis, but the best mode of endoscopic intervention is not clear, and outcomes relating to variables such as gender, medication, alcohol, and smoking are not known. We reviewed the clinical experience with Dieulafoy lesions at our institution, focusing on clinico-epidemiological features, management practices, and also survival. METHODS A retrospective and prospective cohort of patients with Dieulafoy lesions who underwent endoscopy from January 2004 through April 2009 were studied and detailed clinical data were abstracted and collected. RESULTS We identified 63 patients with a Dieulafoy lesion. The majority were male with an average age 58 years. Hematemesis and melena were the most common presenting symptoms. Almost half the patients were on anticoagulation medication. Most of the Dieulafoy lesions occurred in the upper GI tract, and mostly in the stomach. Single-modality endoscopic therapy was used as frequently as combination therapy, and both were effective, as primary hemostasis was achieved in 92% of cases. There were 11 deaths overall; death due to Dieulafoy lesion exsanguination was attributed to three patients. CONCLUSIONS Dieulafoy lesions occurred in younger patients than previously reported, and were more frequently diagnosed in males. Most DL lesions occurred in the upper GI tract. Primary hemostasis with endoscopic therapy was highly successful. Overall mortality was 17%, and associated with co-morbidities, and not with medical history, gender, age, or medication.
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Lee WS, Cho SB, Park SY, Park CH, Joo YE, Kim HS, Choi SK, Rew JS. Successful side-viewing endoscopic hemoclipping for Dieulafoy-like lesion at the brim of a periampullary diverticulum. BMC Gastroenterol 2010; 10:24. [PMID: 20178576 PMCID: PMC2837224 DOI: 10.1186/1471-230x-10-24] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2009] [Accepted: 02/23/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Duodenal Dieulafoy's lesions are rare and only several cases were reported so far. Their characteristic appearance and location make it difficult to be diagnosed in the clinical practice. Massive bleeding often results from these lesions and can impede the accurate early treatment. CASE PRESENTATION 67 years old male patient suffered a fatal bleeding from Dieulafoy-like lesion located at the mouth of the periampullary diverticulum. Initial endoscopic therapy and radiologic embolization failed to stop the bleeding, while direct observation and hemoclipping by the side viewing endoscopy successfully established correct diagnosis and permanent cure of the lesion. CONCLUSION Aggressive endoscopic examinations combined with the accurate endoscopic treatment should be adopted when Dieulafoy-like lesion is suspected as a possible cause of the proximal small bowel hemorrhage. Verification of the diagnosis and definitive treatment often needed repeated examination by side-viewing endoscope as well as stabilization of the patient.
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Affiliation(s)
- Wan Sik Lee
- LDepartment of Internal Medicine, Division of Gastroenterology, Chonnam Medeical University Hwasun Hospital, Hwasun, Jeonnam, South Korea.
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Abstract
AIM: To investigate the incidence, location, clinical presentation, diagnosis and effectiveness of endoscopic treatment of gastric Dieulafoy’s lesion (DL) in China.
METHODS: All patients who received emergency upper gastrointestinal (GI) endoscopy due to gastric DL from February 2000 to August 2008 at GI endoscopy center of Renmin Hospital of Wuhan University were included in this study. The clinical presentation, medical history, location and characteristics of DL methods and effectiveness of therapy of patients with DL were retrospectively analysed by chart reviews. Long-term follow-up data were collected at outpatient clinics or telephone interviews.
RESULTS: Fifteen patients were diagnosized with DL, which account for 1.04% of the source of bleeding in acute non-variceal upper GI bleeding. Common comorbidities were found in one patient with hypertension and diabetic mellitus. Hemoclip or combined therapy with hemoclip produced primary hemostasis in 92.8% (13/14) of patients.
CONCLUSION: DL is uncommon but life-threatening in China. Hemoclip proved to be safe and effective in controlling bleeding from DL.
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Abstract
Classification of vascular abnormalities of the gastrointestinal tract on the basis of anatomy and pathophysiology has recently been suggested. Angiodysplasia, an example of an arteriovenous lesion, may cause either acute or chronic bleeding. Diagnosis may be difficult. High-quality standard endoscopy, capsule endoscopy, and double-balloon enteroscopy are most efficacious. Therapy using argon plasma coagulation is currently preferred. Pharmacological therapy has been employed, but a final conclusion about its efficacy cannot yet be drawn. Dieulafoy lesion, an arterial type of vascular abnormality, is rare but serious. It can be responsible for severe haemorrhage. Mechanical endoscopic methods are the most efficacious. Gastric antral vascular ectasia (GAVE), a capillary lesion, can be safely biopsied; it coincides with several diseases (including liver cirrhosis), may cause chronic iron-deficiency anaemia, and is best treated by argon plasma coagulation. Haemangiomas, benign neoplastic lesions, usually occur as part of other specific syndromes; they are difficult to manage due to the multiplicity and size of the lesions.
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Affiliation(s)
- Jaroslaw Regula
- Department of Gastroenterology, Medical Centre for Postgraduate Education, Institute of Oncology, Warsaw, Poland.
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25
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Glasgow RE, Rollins MD. Stomach and Duodenum. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Nagri S, Anand S, Arya Y. Clinical presentation and endoscopic management of Dieulafoy’s lesions in an urban community hospital. World J Gastroenterol 2007; 13:4333-5. [PMID: 17708606 PMCID: PMC4250859 DOI: 10.3748/wjg.v13.i32.4333] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To identify rates of occurrence, common clinical and endoscopic features, and to review the outcome of endoscopic management of Dieulafoy’s lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting.
METHODS: Endoscopic data from esophagogastroduodenoscopies (EGDs), done at Wyckoff Heights Medical Center, Brooklyn, NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy’s lesions. Demographic data, medical history, examination findings, lab data, endoscopic findings and details of therapy for patients treated for Dieulafoy’s lesions were reviewed retrospectively.
RESULTS: Dieulafoy’s lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding, while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding, prevalence of Dieulafoy’s lesions approached 10 percent. The most common location of the lesion was the body of stomach (7), followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection, in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.
CONCLUSION: Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy, especially in patients with multiple co-morbid conditions, can be very effective and life saving.
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Affiliation(s)
- Srikrishna Nagri
- Department of Gastroenterology, Brooklyn Hospital Center, Brooklyn, NY 11201, United States.
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Iacopini F, Petruzziello L, Marchese M, Larghi A, Spada C, Familiari P, Tringali A, Riccioni ME, Gabbrielli A, Costamagna G. Hemostasis of Dieulafoy's lesions by argon plasma coagulation (with video). Gastrointest Endosc 2007; 66:20-26. [PMID: 17591469 DOI: 10.1016/j.gie.2006.11.022] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2006] [Accepted: 11/10/2006] [Indexed: 02/06/2023]
Abstract
BACKGROUND A Dieulafoy's lesion is a submucosal artery that may erode the epithelium and lead to severe hemorrhages. The safety and efficacy of argon plasma coagulation (APC) for the hemostasis of these lesions has not been studied. OBJECTIVE To evaluate efficacy of APC alone in the hemostasis of Dieulafoy's lesions. DESIGN A retrospective analysis of hemostasis by chart review, with long-term follow-up by outpatient visit or phone interview. SETTING An academic hospital with 24-hour endoscopic service availability. PATIENTS All patients with acute bleeding from a Dieulafoy's lesion treated with APC. INTERVENTIONS Hemostasis was attempted with 2.3-mm APC probes, with settings varying from 40 W to 60 W, according to lesion location. MAIN OUTCOME MEASUREMENTS Initial hemostasis, recurrent bleeding, and 30-day mortality rates. RESULTS Twenty-three Dieulafoy's lesions were treated with APC, which represented 85% of all such lesions observed. Severe comorbidities and abnormal coagulation were present in 39% and 22%, respectively. Dieulafoy's lesions were located in the upper-GI tract in 20 patients (87%). Active bleeding was found in 20 patients (87%), a nonbleeding visible vessel was found in 2 patients (9%), and a minute mucosal defect below an adherent clot was found in 1 (4%). Initial hemostasis was achieved in all patients, without complications. An injection of an average volume of 3 mL of 1:10,000 epinephrine solution preceded APC in 3 cases for the identification of the bleeding lesion. Recurrent bleeding occurred in a patient after 48 hours; no bleeding-related deaths were observed during a median follow-up of 29 months. LIMITATIONS Retrospective study. CONCLUSIONS Dieulafoy's lesions can be successfully managed by APC alone.
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Affiliation(s)
- Federico Iacopini
- Digestive Endoscopy Unit, Department of Surgery, Catholic University, Rome, Italy
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Abstract
Endoscopy plays a central role in the diagnosis and treatment of non-variceal upper gastrointestinal haemorrhage. Advances in endoscopic techniques, supported by an increasing body of high quality data, have rendered endoscopy the first-line diagnostic and therapeutic intervention for the patient presenting with an upper gastrointestinal haemorrhage. However, endoscopic intervention must be considered in the context of the overall management of the bleeding patient, often with significant comorbidities. Although parameters such as hospitalization duration, transfusion requirements and surgery rates have improved with advances in endoscopic therapy, mortality rates remain relatively static. This review addresses the current status of endoscopic intervention for non-variceal upper gastrointestinal haemorrhage. Additionally, an overview of important periprocedural management issues is presented.
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Affiliation(s)
- Vu Kwan
- Department of Gastroenterology, Concord Hospital, Sydney, New South Wales, Australia
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De Palma GD, Patrone F, Rega M, Simeoli I, Masone S, Persico G. Actively bleeding Dieulafoy's lesion of the small bowel identified by capsule endoscopy and treated by push enteroscopy. World J Gastroenterol 2006; 12:3936-3937. [PMID: 16804987 PMCID: PMC4087950 DOI: 10.3748/wjg.v12.i24.3936] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2006] [Revised: 02/06/2006] [Accepted: 02/18/2006] [Indexed: 02/06/2023] Open
Abstract
Dieulafoy's lesion is an unusual cause of recurrent GI bleeding. This report describes a case of actively bleeding Dieulafoy's lesion of the small bowel in which the diagnosis was made by capsule endoscopy, followed by treatment with the use of push enteroscopy. The case illustrates that capsule endoscopy and enteroscopy are highly complementary in patients with small bowel diseases.
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Affiliation(s)
- Giovanni D De Palma
- Centro per l'Innovazione Tecnologica in Chirurgia, Dipartimento di Chirurgia Generale, Oncologica e Tecnologie Avanzate, Universita degli Studi di Napoli Federico II-Facolta di Medicina e Chirurgia, Italy.
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Katsinelos P, Paroutoglou G, Mimidis K, Beltsis A, Papaziogas B, Gelas G, Kountouras Y. Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions. World J Gastroenterol 2005; 11:6022-6. [PMID: 16273618 PMCID: PMC4436728 DOI: 10.3748/wjg.v11.i38.6022] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment.
METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding, and mortality rates were collected and analyzed retrospectively.
RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy’s lesion over a mean long-term follow-up of 29.8 mo.
CONCLUSION: Bleeding from Dieulafoy’s lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy’s lesions.
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Affiliation(s)
- Panagiotis Katsinelos
- Department of Endoscopy and Motility Unit, "G. Gennimatas" Hospital, Ethnikis Aminis 41, Thessaloniki 54635, Greece.
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Katsinelos P, Paroutoglou G, Beltsis A, Papaziogas B, Gouvalas A, Chatzimavroudis G, Vlachakis I, Mimidis K, Vradelis S, Pilpilidis I. Endoscopic Hemoclip Application in the Treatment of Nonvariceal Gastrointestinal Bleeding. Surg Laparosc Endosc Percutan Tech 2005; 15:187-90. [PMID: 16082303 DOI: 10.1097/01.sle.0000174575.52840.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We conducted an uncontrolled retrospective study to evaluate endoscopic hemoclip application as the first-choice hemostatic treatment of gastrointestinal bleeding lesions from a wide variety of sources. Clinical data, endoscopic findings, complications, and short- and long-term outcomes were also investigated. A total of 52 patients (men/women, 36/16; age, 65 +/- 11.5 years) were included in the study. Hemoclipping was technically successful in 51 cases (98%). The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis was 1.42 +/- 1.2 (range, 1-4). The number of hemoclips required for hemostasis depended on the nature of bleeding with the average number of hemoclips used being 3.11 +/- 1.12 (range, 2-8). No complications occurred, although 1 patient presented recurrent bleeding and was operated on. No further hemorrhage occurred during a median follow-up period of 17.32 +/- 5.4 months (range, 2-53). Endoscopic hemoclipping provided an effective and safe modality for achieving hemostasis in gastrointestinal bleeding from a wide variety of sources, with long-term benefits.
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Abstract
AIM: Dieulafoy’s lesion (DL) accounts for 1-5.8% of cases of acute upper gastrointestinal bleeding (GIB). Its mortality is high, approaching 20%, despite recent advances in endoscopic therapy. We aimed to report our experience in the treatment of DL.
METHODS: A retrospective case study of all patients with DL between January 1993 and January 2003 was done. Characteristics, treatment methods, success rates and 30-d mortality of the patients were analyzed.
RESULTS: Thirty-six patients were noted to have DL in the study period. Thirty-three records were available for assessment in which 35 DL were identified. The median age of the patients was 67 years with male to female ratio of 5.6:1. Significant comorbidities existed in 69% of the patients. Eighty-nine percent of the DL was found at first endoscopy, three DL at laparotomy. Significant coexistent endoscopic findings existed in 23%. Hemostasis was achieved in 88% by using adrenaline injection, or in combination with heater probe application at first endoscopy. Four cases had re-bleeding, all were successfully treated endoscopically. The 30-d mortality rate was 23%.
CONCLUSION: Successful endoscopic hemostasis could be achieved in 100% of cases of DL. The overall mortality may still remain high, mainly due to the comorbidities and age of these patients.
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Affiliation(s)
- R S Walmsley
- Department of Gastroenterology, North Shore Hospital, Shakespeare Road, Private Bag 93-503, Takapuna, Auckland, New Zealand.
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Affiliation(s)
- Gilles Lesur
- Fédération des Spécialités Digestives, Hôpital Ambroise Paré, 92104 Boulogne Cedex, France.
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35
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Lin HJ, Perng CL, Sun IC, Tseng GY. Endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection for peptic ulcer bleeding. Dig Liver Dis 2003; 35:898-902. [PMID: 14703887 DOI: 10.1016/j.dld.2003.07.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treating patients of bleeding peptic ulcers with heater probe thermocoagulation and haemoclip is considered to be safe and very effective. Yet, there is no report comparing the haemostatic effects of endoscopic haemoclip versus heater probe thermocoagulation plus hypertonic saline-epinephrine injection in these patients. AIM To compare the clinical outcomes of both therapeutic modalities in patients with peptic ulcer bleeding. METHODS A total of 93 patients with active bleeding or non-bleeding visible vessels were randomised to receive either endoscopic haemoclip (n = 46) or heater probe thermocoagulation plus hypertonic saline-epinephrine injection (n = 47). Five patients from the haemoclip group were excluded because of the inability to place the haemoclip. RESULTS Initial haemostasis was achieved in 39 patients (95.1%) of the haemoclip group and 47 patients (100%) of the heater probe group (P > 0.1). Rebleeding occurred in four patients (10.3%) of the haemoclip group and three patients (6.4%) of the heater probe group (P > 0.1). The volume of blood transfused after entry into the study, duration of hospital stay, number of patients requiring urgent surgery and the mortality rates were not statistically different between the two groups. CONCLUSIONS If the haemoclip can be applied properly, the clinical outcomes of the haemoclip group would be similar to those of the heater probe group in patients with peptic ulcer bleeding. However, if the bleeders are located at the difficult-to-approach sites, heater probe plus hypertonic saline injection is the first choice therapy.
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Affiliation(s)
- H J Lin
- Division of Gastroenterology, Department of Medicine, VGH-TAIPEI, Shih-Pai Road, Sec 2, Taipei 11217, Taiwan, ROC.
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Abstract
PURPOSE OF REVIEW This review provides an updated summary of gastric interventional endoscopy. Relevant original articles and topic reviews are highlighted in the areas of infection control, light sedation, hemostasis, endoscopic mucosal resection, and endoscopic placement of enteric devices. RECENT FINDINGS Several key findings are worth noting: the increased use of propofol by nonanesthesiologists for deep sedation with minimal adverse side effects, the adaptation of tissue adhesive agents for the treatment of bleeding gastric varices, the successful treatment of early gastric cancer by endoscopic mucosal resection, and the development of direct percutaneous endoscopic jejunostomy tubes for patients at high risk of aspiration. SUMMARY These recent developments in the field of interventional endoscopy have already made a great impact on clinical care. More advanced procedures can be performed safely while the patient is under deep sedation. Yet, these developments have not slowed down the need for improvement in interventional endoscopy. Researchers continue to look for smaller instruments, better optics, and more advanced accessories. This constant state of flux marks the field of interventional endoscopy and ensures its progress.
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Affiliation(s)
- Wahid Wassef
- Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
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Katsinelos P, Paroutoglou G, Pilpilidis I, Tsolkas P, Papagiannis A, Kapelidis P, Trakateli C, Iliadis A, Georgiadou E, Kamperis E, Dimiropoulos S, Vasiliadis I. Double Dieulafoy-like lesion in the stomach. Surg Endosc 2003; 17:1324. [PMID: 12799880 DOI: 10.1007/s00464-003-4200-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2003] [Accepted: 01/23/2003] [Indexed: 12/31/2022]
Abstract
Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of an arteriole that protrudes through a tiny mucosal defect usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Emergency endoscopy is the most effective method of diagnosing the disease. We report a patient, with double Dieulafoy-like lesion, who was successfully treated endoscopically using hemostatic clip application. The characteristics of the Dieulafoy's lesion, its current diagnosis, and its treatment are discussed.
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Affiliation(s)
- P Katsinelos
- Department of Endoscopy and Motility Unit, General Hospital George Gennimatas, Thessaloniki, Greece.
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Affiliation(s)
- Yuk Tong Lee
- Department of Medicine, Prince of Wales Hospital, Chinese University of Hong Kong, Shatin, N.T., Hong Kong
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Yamaguchi Y, Yamato T, Katsumi N, Imao Y, Aoki K, Morita Y, Miura M, Morozumi K, Ishida H, Takahashi SI. Short-term and long-term benefits of endoscopic hemoclip application for Dieulafoy's lesion in the upper GI tract. Gastrointest Endosc 2003; 57:653-6. [PMID: 12709692 DOI: 10.1067/mge.2003.183] [Citation(s) in RCA: 57] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Dieulafoy's lesion is an important cause of GI bleeding. The results of hemoclip application as the first treatment of choice for Dieulafoy's lesions have not been reported. This study prospectively examined the short- and long-term outcomes of hemoclip application for Dieulafoy's lesions. METHODS The study was conducted over a 7-year period beginning in January 1995 during which hemoclip application was used as the first-choice hemostatic treatment for Dieulafoy's lesions. Clinical data, endoscopic findings, and outcome of treatment were evaluated. Long-term outcome for patients was also investigated. RESULTS A Dieulafoy's lesion was diagnosed in 34 patients (27 men, 7 women; mean age, 54 years, range 21-81 years) after a mean of 1.2 endoscopies; 79.4% of the patients had active bleeding. Initial hemostasis was attained by hemoclip placement in 94.1%. The rate of recurrent bleeding was 9.3%. No patient required additional treatment such as surgery. The 30-day mortality rate was 2.9% (1 death, unrelated). For the remaining 33 patients, median follow-up was 53.8 months (range 19 to 90 months). Another Dieulafoy's lesion developed in one patient during follow-up, but in a different location compared with the index lesion. CONCLUSIONS Endoscopic hemoclip application for Dieulafoy's lesions was effective and safe with short- and long-term benefits.
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Affiliation(s)
- Yasuharu Yamaguchi
- The Third Department of Internal Medicine, Kyorin University School of Medicine, Tokyo, Japan
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Feu F, Brullet E, Calvet X, Fernández-Llamazares J, Guardiola J, Moreno P, Panadès A, Saló J, Saperas E, Villanueva C, Planas R. [Guidelines for the diagnosis and treatment of acute non-variceal upper gastrointestinal bleeding]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:70-85. [PMID: 12570891 DOI: 10.1016/s0210-5705(03)79046-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- F Feu
- Societat Catalana de Digestologia. Barcelona. España.
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López-Ciudad V, Pato M, Cid J. Hemorragia digestiva alta por lesión de Dieulafoy. Med Intensiva 2003. [DOI: 10.1016/s0210-5691(03)79998-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Wassef W. Interventional endoscopy. Curr Opin Gastroenterol 2002; 18:669-77. [PMID: 17033346 DOI: 10.1097/00001574-200211000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
Technologic milestones have been achieved in the field of interventional endoscopy. These have resulted in improved hemostasis, more accurate cancer staging, safer and less invasive methods of removing gastric neoplasms, and endoscopic palliation of malignant gastric outlet obstruction via stenting. However, just as these milestones are achieved, new challenges emerge: (1) How much sedation can one use safely? (2) What is the risk of transmitting infection and how can that be prevented? (3) Can scopes be made smaller and more comfortable? (4) Can optics be improved? (5) Can endoscopic repair of gastric perforations be safely performed? In this section, we review some of these issues. First, we will provide an update on the most recent concepts in the field of light sedation and infection control. Then, a review of the most commonly used interventional endoscopy procedures, including hemostasis, endosonography, endoscopic mucosal resection, stenting, and percutaneous gastrostomy tube placements. Finally, an overview of the ongoing research and development in the field of interventional endoscopy and how it can improve patient comfort, diagnostic accuracy, therapeutic efficacy, and training in the future.
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Affiliation(s)
- Wahid Wassef
- Division of Gastroenterology, University of Massachusetts Medical Center, Worcester, Massachusetts 01655, USA.
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